Name the 4 Ts of PPH:

Management of PPH:

1. CommunicationAlert all relevant professionals. In minor PPH, this is the midwife in charge, and first-line obstetric and anaesthetic staff. For major PPH, this also includes alerting the obstetric, anaesthetic and haematology consultants as well as the blood transfusion laboratory and porters.

3. Measures to arrest the bleeding

Examination to establish cause, and exclude other causes than uterine atony (the most common cause).

If the cause is established to be uterine atony, the following measures are taken in turn:Bimanual uterine compression to stimulate contraction.Ensure the bladder is empty via catheter.

-Oxytocin 5 units by slow IV infusion. May require repeat.

-Ergometrine 0.5 mg slow IV or IM unless there is a history of hypertension.

-Carboprost 0.25 mg IM repeated to a maximum of 8 doses unless there is a history of asthma.

-Misoprostol 1000 micrograms rectally. If these are not successful consider surgical options:Balloon tamponade.Haemostatic brace suturing - eg, the B-Lynch compression suture.Bilateral ligation of the uterine arteries/ internal iliac arteries.Selective arterial embolisation.Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture. If possible, a second consultant should be involved in this decision.

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Measures to prevent PPH?

The active management of the third stage of labour significantly reduces the risk of PPH. Prophylactic oxytocics should be routinely used in the third stage of labour, as they decrease the risk of PPH by 60%. For most women delivering vaginally, oxytocin 5 or 10 IU IM is the prophylactic agent of choice. It is used as an infusion for women having caesarean sections. Syntometrine® (oxytocin plus ergometrine) may also be used in the absence of hypertension.

Symptoms of secondary PPH?

Look for history of extended labour, difficult third stage, ragged placenta, PPH.

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Investigations in suspected secondary PPH:

FBC.Blood cultures.Check MSU.High vaginal swab; also gonorrhoea/chlamydia.Ultrasound - may be used if RPOC are suspected, although there may be difficulty distinguishing between clot and products. RPOC are unlikely if a normal endometrial stripe is seen.

Speculum!

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Management of secondary PPH:

For endometritis: IV antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. The RCOG guideline for sepsis following pregnancy recommends IV piperacillin/tazobactim.For severe sepsis, carbapenem plus clindamycin. Other options, for less severe infections include co-amoxiclav, metronidazole and gentamicin. However, it stresses guidelines based on local resistance should be followed.

If RPOC are suspected, elective curettage with antibiotic cover may be required. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. These women are carrying a high risk of uterine perforation.

The patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.